When It’s Easier to Get Mad Than Feel Sad

New Therapy Treatment by Ferkauf’s Prout Gets to Heart of ODD and Similar Disorders

Why is it easier to get mad than feel sad? This question is at the heart of a new therapy technique pioneered by Dr. Tracy Prout, assistant professor at the Ferkauf Graduate School of Psychology, and her colleagues, Dr. Leon Hoffman of the New York Psychoanalytic Society and Institute and Dr. Timothy Rice of Mount Sinai St. Luke’s. The goal is to better understand and care for children diagnosed with Oppositional Defiant Disorder (ODD),a condition in which a child displays an ongoing pattern of an angry or irritable mood, defiant or argumentative behavior, and vindictiveness toward people in authority. Labeled as “difficult” or “troublemakers,” these children often suffer dire educational, developmental and social consequences.

Dr. Tracy Prout, assistant professor at Ferkauf, and student Sophia Aizin model a new therapy technique Prout has developed to treat children with ODD. Called Regulation-Focused Psychotherapy for Children, the technique draws on play therapy, above, to engage children directly, rather than working primarily with caregivers to change behaviors.

“When you’re a kid and you have these serious oppositional behaviors, it interrupts development,” said Prout. “You’re not in the classroom because you’re constantly getting kicked out. You’re not participating in the normal life of your family because you’re constantly being removed from the activity. And even if you only miss a few days of school when you’re young, those days are critical. We want to intervene quickly and effectively so these kids can participate in all the things that are so crucial for their development.”

That’s why Prout, Hoffman, and Rice have created a new therapy technique that seeks to improve outcomes for children with ODD-like disorders, especially for those from low socio-economic backgrounds.

Traditionally, these children have been referred to a type of treatment called parent management training or behavioral parent training, which focuses on coaching parents to reinforce positive behaviors and eliminate negative ones. While parent management training has high success rates, it also has its limitations.

“Because their focus is primarily on working with parents, these treatments don’t engage the child directly in treatment, which can be a problem especially if a child is suffering from an emotion regulation deficit—sometimes oppositional behaviors persist because the child lacks the ability to manage complex emotions,” said Prout. “If that’s the case, parent management training may help parents respond differently to their children but it is unlikely to get to the underlying meaning of the oppositional behavior. You can change the way parents behave and that can have a significant impact on the child’s behavior; but you still will not understand what the child was trying to express through the acting out behavior. So much is left unresolved and unprocessed.” The goal of the treatment, she added, is to get to the root of the problem. What causes children to act out in such extreme ways when faced with emotionally difficult situations?

“We see it as a way children protect themselves from other feelings that are harder or more complicated to manage,” saidProut. “It’s easier to fight and argue than say, ‘I’m struggling with shame or loss.’ Many of the kids we work with don’t havethe skills or abilities to regulate those difficult emotions.” Why not? The causes, she explained, can range from organic—for example, issues with neurological development, such as an underdeveloped prefrontal cortex—to situational: ODD is more common among children who have experienced food insecurity, trauma or poverty, as well as those growing up in families where feelings are not discussed or engaged with openly.

At Ferkauf, Prout and a team of colleagues and students are implementing a psychodynamic treatment for ODD that seeks to help affected parents and children not only to create better lives and futures for themselves, but also to understand why and how negative behaviors developed in the first place.

Prout and her collaborators recently published a field handbook on the therapy technique, Manual of Regulation-Focused Psychotherapy for Children (RFP-C) with Externalizing Behaviors: A Psychodynamic Approach.

Called Regulation-Focused Psychotherapy for Children (RFP-C), the program consists of an adaptable short-term intervention that can be delivered in a variety of settings by a range of mental health providers, making it more affordable and more accessible to the families who are likely to benefit from it the most. Patients and their parents are seen twice weekly for 10 weeks. During visits, clinicians observe and join the children as they play and use what’s happening in the room as a framework to discuss patients’ difficulties in a more subtle way that is less threatening for children.

“We’re trying to enhance their ability to regulate those emotions and educate the child and their family about the meaning of their oppositional behaviors,” said Prout. “Just the idea that there is meaning is new to some families. We are also hopeful that our treatment approach will make it less likely that families will drop out because it emphasizes coming to the family from a place of empathy, talking to them about stressors, and involving their children directly in the treatment.”

Last year Prout, Hoffman and Rice co-authored a field handbook on the therapy technique, Manual of Regulation-Focused Psychotherapy for Children (RFP-C) with Externalizing Behaviors: A Psychodynamic Approach. While Prout and her colleagues have been using this technique in their clinical practices for years, they have recently been awarded three grants to empirically test RFP-C and build the evidence base for the approach. A grant of $10,000 from the New York Psychoanalytic Society and Institute funded a pilot study with three participants. Promising results from that study are currently under review for publication. A two-year, $102,000 grant from The FAR Fund is supporting the group’s first randomized control trial which compares the outcomes of children treated with RFP-C versus others who are waitlisted.

Prout’s students Sophia Aizin and Tali Clements, both enrolled in Ferkauf’s School-Clinical Child Psychology Program, were also awarded a $2,000 grant from the New York State Parenting Education Partnership to run two parenting groups based on RFP-C. These groups are designed to help mothers of children with oppositional behavior improve their ability to help and interact with their children. The two have presented their research at two national conferences this year. According to Aizin, the parents she’s worked with are already seeing a difference.

“I was struck by this mom that came in who was so overwhelmed and said to us, ‘I’ve looked and looked and there’s not anything like this in the Bronx,’ ” Aizin said. “Especially among families where there are so many stressors, a group that brings together mothers who struggle to understand their children can potentially be really impactful. It just made me feel like, that’s why we’re here. That’s why we’re doing this.”